Confidential Prescription Drug Assessment

Fill out our Confidential Prescription Abuse and Addiction Assessment

Fill out the form below as accurately as possible so we can better assess the situation of the person needing help. All answers will be kept confidential. There is no charge for this consultation.

First Name: *
Last Name:
City: *
State: *
Phone: *
E-mail Address: *
Time Zone: *
Best Time to Contact You: *
Seeking Help For: *
Age Group: *
Does the User Admit to Having a Problem? *	Yes No
What is the Primary Drug Abused? *
Other Drugs Being Used?
Has the User Ever Tried and Failed to Control, Cut Down or Stop Using? *	Yes No
Describe the current scene regarding the users situation with drinking or drug use. *

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Effects of Prescription Drug Abuse

Long-term use of opioids or central nervous system depressants can lead to physical dependence and addiction. Opioids produce drowsiness, and depending on amount taken, can depress breathing. Central nervous system depressants slow down brain function; if combined with other medications that cause drowsiness or with alcohol, heart rate and respiration can slow down dangerously. Taken repeatedly or in high doses, stimulants can cause anxiety, paranoia, dangerously high body temperatures, irregular heartbeat, or seizures.